Trauma-informed Care for Every Body (Part 2)

In the last issue, we started talking about weight stigma as a form of trauma with detrimental effects on health, and our role in perpetuating and worsening weight stigma with practices such as weighing at every visit, frequent reminders to lose weight regardless of the problem patients present with, and largely ineffective, often shame-inducing advice for self-guided “diet and exercise”. We also explored the inaccuracy of assumptions that thinness equals health, what a flawed proxy BMI is for health, and BMI’s origins in an entirely white European population. We will now talk more about weight and trauma, disordered eating, and some starting points to reduce weight stigma in our practices.

Trauma has long been recognized as a contributing factor to increased body weight. The original study on Adverse Childhood Experiences (ACEs) in 1985 was born out of Dr. Vincent Felitti’s observation in a weight loss clinic that among women who dropped out of the program, a majority (55%) had experienced sexual abuse. Several studies since have confirmed an association between trauma and heavier weight (e.g., Richardson et al. 2014, Wiss et al. 2020).

In addition to trauma leading to higher weight, higher weight in turn also commonly leads to toxic stress and trauma from weight discrimination and weight stigma. Health At Every Size (HAES) and others have posed an important question: to what degree are adverse health outcomes caused by the toxic stress from weight discrimination and weight stigma, rather than by the fat itself?

There is ample evidence of the adverse effects of weight stigma on health and well-being. Internalization of weight bias has been shown to be a link between weight bias and poor health outcomes. Weight bias internalization refers to the degree to which a person has started directing weight stigma at themselves and can be measured with the Weight Bias Internalization Score (WBIS).

Pearl & Puhl (2013) showed that a higher WBIS were associated with body image disturbance, poor self-esteem, anxiety and depression, and, in particular, disordered eating. Contrary to common belief, most individuals with disordered eating do not have low, but high BMIs. Binge eating disorder rates are especially high among patients at higher weights and are associated with poor mental health and poor quality of life.

It is easy to see how our incessant highlighting and focusing on our patients’ need for weight loss reaffirms patients’ internalized weight stigma and thus reenforces disordered eating. To make things worse, when we tell people to “diet”, we are basically telling them to adopt eating patterns we know to be harmful in thin people: restricted eating, feeling guilt and shame about eating, being overly preoccupied with eating, etc.

There is overwhelming evidence of the detrimental harm eating disorders cause, and we as healthcare providers are part of the problem. Additionally, evidence shows that the most detrimental cardiovascular health outcomes are associated with weight cycling, which is often a consequence of self-directed dieting.

How can we do better? How do we reduce healthcare’s contribution to internalized weight bias, disordered eating, and other poor health outcomes? The 4R’s of traumainformed care (i.e., realize, recognize, resist, respond) provide a helpful framework for this (see table, page 28). This is a very complex topic, and there is much to unpack from what we were taught. Ultimately, as with other biases, fighting weight bias means to see the individual for who they truly are, in all their complexity, personality, beauty, strengths and weaknesses, unpretentiousness, vulnerability and totally badass-ness.

Primary Care: FM Opportunities

At the end of the day, this is where you want to be.

Join the Banner Health Team, in an outdoor paradise where the beautiful Sierra Nevada and Cascade mountains meet the desert of the Great Basin in Susanville, California –where you’ll have the time to connect with your patients, your practice, your family and the great outdoors! We offer dedication to work/life balance unmatched in our industry. Meaning you get to spend more time doing what you love. That’s HEALTH CARE made easier, LIFE made better!

• $240K Salary Guarantee

• $100K Sign-On Bonus

• $100K Educational Loan Repayment

• Eligible for $50K from California Health Planning

• Eligible for Public Service Loan Forgiveness

• Eligible for HRSA Educational Loan Repayment

• Retention Bonus

• Focus on Patient and Provider Well-Being

• Top of Market Compensation and Benefits

Join our Provider Talent Network! Register using our job portal: PracticeWithUs.BannerHealth.com Or, email CV: primarycaredocs@bannerhealth.com For information call Martha Gonzales 602.747.4328 continued from page 26

Banner Health is an EEO/AA - M/W/D/V Employer.

REALIZE (the impact of trauma and stress and paths to recovery):

- High weight can both result from and result in trauma.

- Weight stigma, including in healthcare, is experienced by most individuals at high weight, and is a form of toxic stress and trauma.

- Internalized weight stigma is very common (even in individuals with normal BMI!) and associated with disordered eating and other poor health.

- Thin does not equal good health, fat does not equal poor health, and BMI is a poor proxy for health.

RECOGNIZE (signs and symptoms of trauma and stress):

- Ask your patients about weight bias, prior experiences in healthcare, internalized weight stigma, disordered eating, and trauma history to the degree the patient feels comfortable talking about.

- Learn to recognize if your audience is in “learning brain” or in “survival brain” (stress response, flipped lid). A brain in “survival mode” cannot learn at that moment. Focus instead on addressing the toxic stress.

RESIST re-traumatization:

- Give patients a choice if they want to be weighed at a visit.

- Ask permission to talk about weight.

- Use body-positive language.

- Stop blaming patients and individual lack of effort for weight. Recognize weight is complex, multifactorial.

- Do not encourage self-directed “dieting” due to both its ineffectiveness and general worsening of internalized weight bias and feelings of shame and guilt when it does not work.

- Empower them to develop a positive relationship with food.

- Enlist the help of a nutritionist familiar with body positivity, cultural humility and disordered eating if the patient would like that.

- Know available resources for medically supervised non-surgical or surgical weight loss programs if a patient desires that and find out which weight loss programs/ providers in your area include an emphasis on self-compassion, body positivity and cultural humility.

- Stop simply advising “exercise”. Explore what movement individual patients may find enjoyable, what they would like to and be able to engage in. Strongly discourage tying “exercise success” to weight loss. Physical activity generally improves the sense of well-being, reduces stress and improves cardiorespiratory fitness, but does not necessarily result in weight loss.

RESPOND (by integrating knowledge of trauma and stress):

- Create welcoming spaces: seating areas, gowns and equipment that accommodate a variety of sizes.

- All interventions must be patient-driven. Explore what “health” means to them.

- Openly address cultural and historical issues around the white-centric roots of creating the BMI norms, white supremacist roots of the thinness ideal, and the extremely important paradigm shift that “eating healthy food” does not mean “eating white people food”.

- Empower them with tools for self-compassion and body positivity. Enlist the help of a therapist if the patient would like that.

- To the extent the patient desires that, manage stress, mental well-being, sleep quality, ability to move and engage in life activities.

- Consider alternatives to weight-gain causing medications.

- Reflect on your own weight bias towards others as well as towards your own body and weight. Consider doing the Harvard Weight Bias exercise and take the Weight Bias Internalization Score (Modified) WBIS-M questionnaire yourself. As with other forms of trauma and toxic stress, consider exploring this with the help of a therapist. We need to take care of ourselves in order to be able to be our best selves in this work.